Read the full stored bill text
HLS 26RS-3067 REENGROSSED
2026 Regular Session
HOUSE BILL NO. 1236 (Substitute for House Bill No. 866 by Representative Dewitt)
BY REPRESENTATIVE DEWITT
INSURANCE: Provides relative to pharmacy benefit managers reimbursements
1 AN ACT
2 To amend and reenact R.S. 22:1868(B)(introductory paragraph), (1),(2), and (4), and (C),
3 to enact R.S. 22:1868(B)(5), (D), and (E), and 1868.2, and to repeal R.S.
4 22:1868(B)(2) and (C)(2), relative to pharmacy benefit managers; to provide for
5 definitions; to provide for pharmacy reimbursements; to prohibit certain
6 reimbursement cost assignments; to provide for certain prohibitions; to provide for
7 an effective date; to provide for retroactive application; to provide for authorization
8 of copayment assistance benefits; and to provide for related matters.
9 Be it enacted by the Legislature of Louisiana:
10 Section 1. R.S. 22:1868(B)(introductory paragraph), (1),(2), and (4), and (C) are
11 hereby amended and reenacted and R.S. 22:1868(B)(5), (D), and (E) and 1868.2 are hereby
12 enacted to read as follows:
13 §1868. Local pharmacy reimbursement; National Average Drug Acquisition Costs;
14 appeals
15 * * *
16 B. For purposes of this Section, the following definitions shall apply:
17 (1)(a) "Acquisition cost" means the set of National Average Drug Acquisition
18 Costs, "NADAC", as calculated by the Centers for Medicare and Medicaid Services
19 and reflected in the most recently released public file. means the amount a local
20 pharmacy actually pays to purchase a prescription drug or device, as evidenced by
Page 1 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
HLS 26RS-3067 REENGROSSED
HB NO. 1236
1 a wholesaler or manufacturer invoice, and shall not be less than the National Average
2 Drug Acquisition Cost or NADAC published by the Centers for Medicare and
3 Medicaid Services on the date the prescription drug is dispensed.
4 (b) For drugs for which no NADAC rate is published, acquisition cost means
5 the local pharmacy's documented invoice cost or if no invoice is available, the
6 wholesale acquisition cost as published in a nationally recognized drug pricing
7 compendium on the date of dispensing.
8 (c) "Acquisition cost" is not defined by or determined at the sole discretion
9 of a pharmacy benefit manager or third-party administrator.
10 * * *
11 (4) "Reimbursement formula" means a prescription drug reimbursement
12 calculation involving an ingredient price, calculated based on a prescription drug
13 pricing benchmark plus an adjustment factor, and a professional dispensing fee.
14 (5) "Professional dispensing fee" means a fee that meets all of the following:
15 (a) Incurred at the point of sale or service and pays for costs in excess of the
16 ingredient cost of a covered outpatient drug each time a covered outpatient drug is
17 dispensed.
18 (b) Includes only pharmacy costs associated with ensuring that possession
19 of the appropriate covered outpatient drug is transferred to a beneficiary. Pharmacy
20 costs include but are not limited to reasonable costs associated with a pharmacist's
21 time in checking the computer for information about an individual's coverage,
22 performing drug utilization review and preferred drug list review activities,
23 measurement or mixing of the covered outpatient drug, filling the container,
24 beneficiary counseling, physically providing the completed prescription to the
25 beneficiary, delivery, special packaging, and overhead associated with maintaining
26 the facility and equipment necessary to operate the pharmacy.
27 (c) Does not include administrative costs incurred by the state in the
28 operation of the covered outpatient drug benefit including systems costs for
29 interfacing with pharmacies.
Page 2 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
HLS 26RS-3067 REENGROSSED
HB NO. 1236
1 C. Notwithstanding any provision of law to the contrary, effective January
2 1, 2026, a pharmacy benefit manager shall meet all of the following requirements for
3 claims submitted by any local pharmacy to a pharmacy benefit manager
4 administering claims on behalf of a health plan, except for the Office of Group
5 Benefits:
6 (1) Adopt a reimbursement formula using either NADAC as the prescription
7 drug pricing benchmark or, if NADAC is not available, the wholesale acquisition
8 cost. or, with prior written approval by the commissioner, an alternative prescription
9 drug pricing benchmark that results in claim payment errors that are both comparable
10 to or less than NADAC in terms of frequency and smaller than NADAC in terms of
11 magnitude.
12 (2)(a) Adopt a reimbursement formula using a professional dispensing fee
13 that is an amount not less than the professional dispensing fee established by the
14 Louisiana Department of Health for the Louisiana Medicaid program.
15 (b) The professional dispensing fee shall reflect the actual costs of the
16 professional services provided by the pharmacists, and expenses related to the
17 physical act of dispensing.
18 (3) Adopt an appeal process for pharmacists to challenge claim payment
19 errors that, at a minimum, meets all of the following requirements:
20 (a) A network pharmacy contract executed by and between a pharmacy
21 benefit manager and a pharmacy located in Louisiana shall, at a minimum, contain
22 a provision expressly acknowledging that if a Louisiana pharmacy's reimbursement
23 for any covered drug or device is less than the pharmacy's acquisition cost for that
24 drug or device, the pharmacy has the right to appeal that reimbursement and, if
25 successful, receive additional payment so that the total reimbursement is equal to the
26 pharmacy's demonstrated acquisition cost. The pharmacy benefit manager shall
27 direct the pharmacy to the pharmacy benefit manager's electronic and written appeal
28 locations.
Page 3 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
HLS 26RS-3067 REENGROSSED
HB NO. 1236
1 (b) Permit appeals to be filed for a period of fifteen days following the
2 applicable date of payment.
3 (c) If an appeal is filed with the pharmacy benefit manager, the pharmacy
4 must shall include a written invoice from the wholesaler that includes the drug name,
5 national drug code number, purchase date, and cost of the drug.
6 (d) If a claim payment error occurred, the pharmacy benefit manager shall
7 make an additional payment to the pharmacy to increase the reimbursement amount
8 to the acquisition cost. The pharmacy benefit manager is prohibited from amending
9 or changing the amount a prescription drug consumer must pay for an out-of-pocket
10 cost share or expense.
11 (e) The pharmacy benefit manager shall individually notify all pharmacies
12 using the same customary supplier or wholesaler that a claim payment error occurred
13 and that the pharmacy may reverse and resubmit the claim to correct the claim
14 payment error. The pharmacy benefit manager shall make retroactive price
15 adjustments in the next payment cycle.
16 (f) If a pharmacy benefit manager determines that a claim payment error did
17 not occur, it shall provide the pharmacy or pharmacist with an explanation of why
18 it has upheld the payment, including a specific documentation of the acquisition cost
19 on the date of service. The explanation shall be provided electronically or in writing
20 through customary means of communication between the pharmacy benefit manager
21 and the pharmacy or pharmacist. The explanation shall also include a notice in at
22 least ten-point font stating that, if the pharmacy or pharmacist disagrees with the
23 decision, the pharmacy or pharmacist may file a complaint with the Department of
24 Insurance.
25 D. A pharmacy benefit manager in this state bears all costs associated with
26 the reimbursement of professional dispensing fees. These costs shall not be assigned
27 to plans, members, pharmacies, or pharmacists.
28 E. The commissioner may require submission of claims-level data, including
29 but not limited to reimbursement amounts, dispensing fees, and any adjustments for
30 the purpose of verifying compliance with this Section.
Page 4 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
HLS 26RS-3067 REENGROSSED
HB NO. 1236
1 §1868.2. Authorization of copay assistance benefit plans
2 A health insurance issuer or pharmacy benefit manager may implement
3 copayment assistance benefit plans, also known as copay maximizer plans, for its
4 members or enrollees as permitted by federal law. Participation by a member or
5 enrollee is optional.
6 Section 2. R.S. 22:1868(B)(2) and (C)(2) are hereby repealed in their entirety.
7 Section 3. The provisions of this Act shall be given prospective and retroactive
8 application. The reimbursement formula created in this Act shall be adopted retroactively
9 to January 1, 2026.
10 Section 4. This Act shall become effective upon signature by the governor or, if not
11 signed by the governor, upon expiration of the time for bills to become law without signature
12 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
13 vetoed by the governor and subsequently approved by the legislature, this Act shall become
14 effective on the day following such approval.
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 1236 Reengrossed 2026 Regular Session Dewitt
Abstract: Provides for pharmacy reimbursement guidelines. Prohibits certain
reimbursement cost assignments and cost changes to certain prescription drugs.
Present law prohibits pharmacy benefit managers or persons acting on behalf of a pharmacy
benefit manager from reimbursing a contracted or local pharmacy or pharmacist in this state
an amount less than the acquisition cost for the covered drug, device, or service. Proposed
law retains present law.
Present law defines certain terms. Proposed law adds "professional dispensing fee" to the
list of definitions and otherwise retains present law.
Proposed law provides additional reimbursement guidelines for a pharmacy benefit manager
claim submitted by any local pharmacy to a pharmacy benefit manager administering claims
on behalf of a health plan, except for the Office of Group Benefits.
Proposed law retains present law relative to appeals process for pharmacists to challenge
claim payment errors.
Proposed law prohibits pharmacy benefit managers from amending or changing the amount
a prescription drug consumer must pay for an out-of-pocket cost share or expense.
Page 5 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
HLS 26RS-3067 REENGROSSED
HB NO. 1236
Proposed law permits a health insurance issuer or pharmacy benefit manager to implement
copay assistance benefit plans, also known as copay maximizer plans, for its members or
enrollees as permitted by federal law. Proposed law provides that participation by a member
or enrollee is optional.
Proposed law requires pharmacy benefit managers to bear all costs associated with the
reimbursement of professional dispensing fees. Proposed law prohibits such costs from
being assigned to plans, members, pharmacies, and pharmacists.
Proposed law authorizes the commissioner of insurance to require submission of
claims-level data, including but not limited to reimbursement amounts, dispensing fees, and
any adjustments, for the purpose of verifying compliance with proposed law.
Proposed law provides that the provisions of proposed law shall be given prospective and
retroactive application.
Proposed law requires the reimbursement formula created by proposed law to be
retroactively adopted dating back to Jan. 1, 2026.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Amends R.S. 22:1868(B)(intro. para.), (1), (2), and (4), and (C); Adds R.S. 22:1868(B)(5),
(D), and (E) and 1868.2; Repeals R.S. 22:1868(B)(2) and (C)(2))
Summary of Amendments Adopted by House
The House Floor Amendments to the engrossed bill:
1. Re-define the term "reimbursement formula".
2. Add provision that a health insurance issuer or pharmacy benefit manager may
implement copay assistance benefit plans, also known as copay maximizer plans,
for its members or enrollees as permitted by federal law. Participation by a
member or enrollee shall be optional.
3. Provide for retroactive application for the reimbursement formula.
4. Repeal statutory provisions in present law (R.S. 22:1868(B)(2) and (C)(2)).
5. Make technical changes.
Page 6 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.